Category Archives: Most Wanted List

Remember Bellingham

By Member Jennifer Homendy

Today marks the 20th anniversary of the Olympic Pipe Line rupture in Bellingham, Washington, which resulted in the release of about 237,000 gallons of gasoline into a creek that flowed through Whatcom Falls Park. Sometime after the rupture, the gasoline ignited and burned about 1.5 miles along the creek. Two 10-year-old boys and an 18-year-old young man named Liam Wood died; 8 others were injured.

Bellingham, WA
Postaccident aerial view of portion of Whatcom Creek showing fire damage.

Liam had just graduated from high school and was fly fishing when he was overcome with fumes from the rupture. Years later, I met Liam’s stepfather, Bruce Brabec, as a staffer on Capitol Hill. Since Liam’s death, Bruce has been a tireless advocate for closing gaping holes in pipeline safety regulations, many of which have been revealed as a result of our pipeline accident investigations.

This past fall, I saw Bruce at a pipeline safety conference. The discussions over the days that followed left me wondering how much we’ve accomplished over the last 20 years. Is our pipeline system truly safer?

From a numbers standpoint, it’s good news and bad news. According to the Pipeline and Hazardous Materials Safety Administration (PHMSA), there were 275 significant gas and hazardous liquid pipeline incidents in 1999, resulting in 22 fatalities and 208 injuries. Since that time, the number of significant incidents has fluctuated as PHMSA adopted new reporting criteria, with 288 significant incidents occurring in 2018.

Fatalities and injuries have decreased since 1999 to 7 fatalities and 92 injuries in 2018, but that provides no comfort for victims, their families, or their loved ones. The fact is, although pipelines are one of the safest ways to transport hazardous material, the impact of just one incident can be devastating. And although the number of accidents is low compared to other modes like highway and rail, there is much more that pipeline operators and federal regulators can do to get to zero incidents, zero fatalities, and zero injuries on our nation’s pipeline system.

Our recommendation for operators to install automatic or remote-control shut-off valves in high‑consequence areas is a perfect example. In 1994, we investigated a natural gas transmission pipeline rupture in Edison, New Jersey, which resulted in a fire that injured 112 people and destroyed 8 buildings. Pipeline operators were unable to shut down the gas flow to the rupture for 2½ hours. Our report on the accident recommended that the Research and Special Programs Administration (RSPA), PHMSA’s predecessor, expedite requirements that automatic- or remote‑operated mainline valves be installed on high-pressure pipelines in urban and environmentally sensitive areas so that failed pipeline segments can be rapidly shut down. We have been recommending valve installation in some form on pipelines since 1971.

In response, RSPA issued a regulation requiring operators to install a valve only if the operator determines it will efficiently protect a high-consequence area in the event of a gas release.

Fast forward to September 9, 2010, when an intrastate natural gas transmission pipeline owned and operated by the Pacific Gas and Electric Company ruptured in a residential area in San Bruno, California. The rupture produced a crater about 72 feet long by 26 feet wide. The section of pipe that ruptured was found 100 feet south of the crater. The released natural gas ignited, resulting in a fire that destroyed 38 homes and damaged 70. Eight people were killed, many were injured, and many more were evacuated from the area.

In our report on the accident, we once again recommended that PHMSA expedite the installation of automatic shutoff valves and remote-control valves on transmission lines in populated areas, drinking water sources, and unusually sensitive ecological resources. Congress then required PHMSA to implement the recommendation in the Pipeline Safety, Regulatory Certainty, and Job Creation Act of 2011 (PL 112-90).

It’s been a decade since San Bruno, and PHMSA is nowhere near issuing a final rule to implement our recommendation. This issue is highlighted on our 2019–2020 Most Wanted List of transportation safety improvements (Ensure the Safe Shipment of Hazardous Materials).

MWL03s_HazMat

It’s my hope that over the next few years, we’ll see some real improvements in pipeline safety and avoid tragedies like the ones in Bellingham and San Bruno. With the technology we have readily available today, there’s absolutely no reason for any parent to have to face the loss of a child because of a pipeline accident. I hope that the next time I see Bruce Brabec, we’ll finally have the regulations in place that he’s worked so hard for on Liam’s behalf.

 

 

 

 

The Golden Spike at 150

By Member Jennifer Homendy

The ceremony for the driving of the golden spike at Promontory Summit, Utah on May 10, 1869; completion of the First Transcontinental Railroad. At center left, Samuel S. Montague, Central Pacific Railroad, shakes hands with Grenville M. Dodge, Union Pacific Railroad (center right). (Source: Wikimedia)

On May 10, 1869, 150 years ago today, a golden spike was driven home at Promontory Summit, in what was then the Utah Territory, by Central Pacific Railroad President Leland Stanford. This momentous event joined the Central Pacific and Union Pacific Railroads, completing the first transcontinental railroad, just 7 years after President Abraham Lincoln signed the Pacific Railway Act authorizing land grants and government financing to US railroads for the purpose of joining the east and the west.

As we know, the project was a tremendous success, but it certainly had its challenges.

In 1863, another act established the gauge for the project at 4 ft., 8½ inches (which became the standard gauge). At the time, gauges varied among railways in the United States. The goal of the transcontinental railroad was to ensure that two railroads met in Utah and were “interoperable” when it came time to begin service. A small difference in width would mean no transcontinental railroad: passengers and freight would have to be offloaded to a new train when incompatible rails met, creating a bottleneck affecting thousands of miles of track.

It wouldn’t have inspired confidence in the transcontinental railroad if the four final spikes couldn’t be driven in because the railroad gauges didn’t match!

Leland Stanford, the man who drove the golden spike, went on to found Stanford University. He could not imagine the contributions to transportation that his namesake university would make, including those to the global positioning system used in positive train control (PTC) systems.

Just as the Central Pacific and Union Pacific Railroads worked to ensure their track was seamless, today’s railroads are focused on implementing PTC by ensuring interoperability among many systems­—passenger, commuter, and freight trains must be able to seamlessly communicate and operate across all railroad networks.

PTC isn’t new. The NTSB has been urging railroads to implement it, in some form, since 1970, 1 year after the United States met President John F. Kennedy’s challenge to land a man on the moon. Since then, the NTSB has investigated 152 PTC-preventable accidents that resulted in more than 300 fatalities and 6,700 injuries. PTC remains on our Most Wanted List of transportation safety improvements.

Seven years passed between when Lincoln signed the Pacific Railway Act in 1862 to when the golden spike was driven home at Promontory Summit. Eight years passed from JFK’s speech to Congress about a moonshot in 1961 to Neil Armstrong’s first steps on the gray dust of the lunar surface. PTC was mandated by Congress in the Rail Safety Improvement Act of 2008. It has now been more than 10 years since the act was signed into law.

Today’s golden spike celebration might well feature photos of two locomotives posed head-to-head, as they were for the original golden spike celebration 150 years ago. Perhaps that would also be a fitting image to promote PTC, which, among other safety benefits, would automatically stop trains in time to prevent train-to-train collisions.

As we commemorate 1869’s golden spike, the NTSB continues to await implementation of fully operational PTC, which is long overdue. Let’s end the wait and start planning our own commemoration of the day we finally made all rail travel exponentially safer.

 

Global Road Safety Week

By Nicholas Worrell, Chief, Safety Advocacy Division

Around the world, about 1.25 million people lose their lives every year in motor vehicle crashes. That’s roughly the entire population of Dallas, Texas. Others—20–50 million—are injured or disabled. That’s about the equivalent of injuring everybody in a medium-sized country, like Spain (46 million) or Ukraine (44 million).

May is Global Youth Traffic Safety Month (GYTSM), and May 6–12, 2019, marks the Fifth United Nations Global Road Safety Week. These events draw attention to the need for stronger road safety leadership to help achieve a set of global goals. International governments have set an ambitious goal to reduce by half the number of deaths and injuries from road traffic accidents globally by 2020.

On behalf of the NTSB, during this GYTSM, I’ll join with advocates and road safety experts from around the world to launch action through the ongoing campaign “Save Lives—#SpeakUp.” The campaign “provides an opportunity for civil society to generate demands for strong leadership for road safety, especially around concrete, evidence‑based interventions.” From May 8 to 10, I’ll also have the opportunity to speak to an audience of public transportation agencies from throughout the Caribbean region, as well as road transportation professionals and academics from around the world, at the 8th annual Caribbean Regional Congress of the International Road Federation in Georgetown, Guyana. As a Caribbean native, I am especially looking forward to discussing the NTSB’s lessons learned, recommendations, and advocacy efforts with professionals there.

One of the big messages I hope to get across is that ending road crashes and their resulting injuries and fatalities worldwide will require a cultural shift, and that shift must begin with young people, who are more likely to die in a motor vehicle crash than any other age group. More people between the ages of 15 and 29 lose their lives in crashes than from HIV/AIDS, malaria, tuberculosis, and homicide combined. GYTSM is a time to encourage this demographic to take the mantel and fight to change those statistics.

To learn more about our work in support of Global Youth Traffic Safety Month read some of our past NTSB blog posts https://safetycompass.wordpress.com/?s=global+youth+traffic+safety+month.

Would you like to add your voice to the conversation happening this week around Global Road Safety Week?  Join the Youth For Road Safety global youth Twitter chat on Friday, May 10, 2019, from 15:00–16:00 GMT (10:00–11:00 EST), follow @Yours_YforRS and use the hashtag #SpeakUpForRoadSafety.

 

 

Drink or Drive—Pick One

By Member Jennifer Homendy

The United States continues to be one of the world’s leaders in drunk-driving deaths. One of the reasons for this shameful distinction is that US drivers are allowed to operate motor vehicles with more alcohol in their system than is permitted in most other countries.

Global 05 BAC Image

One state in the nation is an exception to this rule: Utah, which became the first state to lower the threshold for drunk driving from .08 percent blood alcohol concentration (BAC) to .05 percent BAC, joining more than 100 countries that have a limit of .05 percent or lower. In 1983, Utah was also the first state to lead the nation in lowering the threshold from .10 percent to .08 percent BAC.

Currently, California and Michigan legislators are considering whether to adopt a .05‑percent law that will save hundreds of lives and prevent thousands of life-altering injuries over the coming years. On April 3, NTSB Safety Advocate Leah Walton added her voice to the growing chorus calling for a lower BAC limit in California, for the same reasons that I spoke in favor of a similar law in Michigan on March 20, and for the same reasons that the NTSB advocated in support of Utah’s .05 law, which went into effect December 30, 2018. (New York is also considering such a move.) All three laws satisfy our 2013 safety recommendation to lower the legal BAC limit to .05 percent or lower. All three laws will separate drinking from driving, and, by doing so, all three laws will save lives.

Our .05-percent BAC limit safety recommendation was adopted in our safety study, Reaching Zero: Actions to Eliminate Alcohol-Impaired Driving. Numerous other studies, including a recent study by the National Academy of Sciences, have reached the same conclusion: .05‑percent limits save lives.

Let me be clear: we aren’t trying to stop people from drinking; we’re working to stop people from drinking and driving. Our goal is to save lives, and our concerns are justified. In the past 10 years, more than 100,000 people have died in alcohol-involved crashes in the United States.  According to the National Highway Traffic Safety Administration, 10,874 people died in driving-under-the-influence crashes in 2017, the last full year on record. Clearly, .08-percent limits just aren’t working.

Reducing the legal BAC limit for driving is a broad deterrent that lowers the incidence of crashes and crash deaths at all BAC levels, not just those in the narrow range between .05 and .079 percent. It’s estimated that lowering the legal BAC limit in every state would likely reduce the number of fatal alcohol-related crashes by 11 percent, potentially saving up to 1,790 lives a year.

Other safety organizations have done their own great work in support of a .05-percent or lower BAC limit. The World Health Organization; the National Academies of Sciences, Engineering and Medicine; Advocates for Auto and Highway Safety; the National Safety Council; and Mothers Against Drunk Driving have all supported our safety recommendation. A .05-percent BAC limit is also supported by a majority of US motorists—63 percent, in fact, according to the AAA 2015 Traffic Safety Culture Index.

It’s noteworthy that even countries with higher alcohol consumption per capita than the United States set their BAC limits at .05 percent or lower. It’s not that people in these countries don’t drink; they just don’t drink and drive.

Growing up, my parents taught me not to drink and drive. It was just that simple. I never once heard anyone tell me it was OK to “only drive a little drunk.” My parents never lectured me that I could drink and drive as long as I kept my BAC below a certain limit.

And that’s the goal of the .05-percent movement—separating drinking from driving. You can drink responsibly. You can drive responsibly. But no one can responsibly drink and drive.

Our goal is not to propose a new target number of drinks to have before driving; rather, it’s for people to plan to either drink or drive. But never to do both.

 

Eyes on The Road, Hands on the Wheel, Mind on One Task

By Nicholas Worrell, Chief, Safety Advocacy Division

On April 3, I represented the National Transportation Safety Board (NTSB) at an event kicking off Distracted Driving Awareness Month and California Teen Driver Safety Week, in Sacramento. I challenged California to lead the nation in acting on NTSB’s 2011 recommendation to ban the nonemergency driver use of portable electronic devices that do not support the driving task. So far, many states have banned driver use of handheld phones, and all but three have banned texting and driving. But none go as far as our recommendation demands.

Sacramento CA - Press Conference
NTSB Chief of Safety Advocacy, Nicholas Worrell (at podium) addresses media at the April 3, 2019, Distracted Driving Awareness Month kick-off event in Sacramento, CA.

Since the Sacramento event, I’ve spoken about the recommendation to radio and television outlets in the Golden State, some with call-in segments, and I’ve read the comments on news websites covering my kickoff remarks. I’ve learned a lot about what most troubles (and impresses) people about the proposal:

  • Many gave examples of their experiences with dangerous distracted driving behavior on the road and supported the safety recommendation.
  • Some pointed out their personal ability to multitask (an ability at odds with the science of distraction).
  • Some disparaged the danger compared to other distractions (eg, people eating or putting on their makeup).
  • Some asked how the law can be enforced. Indeed, this is certainly a challenge, but one that could be addressed with technology, especially if device-makers get on board. California already bans all nonemergency use of these devices for young drivers and bus drivers, so there’s precedent.
  • Finally, many pointed to technology solutions, and I believe that they’re spot-on. In fact, in response to the same crash that spawned our proposed cell phone ban, we also issued a recommendation encouraging the Consumer Electronics Association to work with its members to disable drivers’ cell phones while driving (except for emergency use, and for use in support of the driving task). We would love to have a meaningful dialogue with device manufacturers through the CEA.

Distracted(4).jpgWhen you talk on a cell phone or become engaged with phone operations, your mind is not on the driving task. Have you ever shushed a passenger while you try to decide if you’re at your freeway exit? How about missed a turn or blown past a stopped school bus while having a conversation on your Bluetooth-enabled, hands-free smartphone? It turns out that we can’t really multitask. We slow down as we disengage from one task and engage in another. It even takes us longer to disengage and reengage our visual focus, to say nothing of completing a competing cognitive task. To experience this lag, just run through the first 10 letters of the alphabet out loud as quickly as you can. Then do the same with the numbers 1 to 10. Then try them together: A-1, B-2, and so on. Do you slow down when “multitasking”? Most people do.

People are quick to admit that manual and visual distraction can cause crashes, but few understand that cognitive distraction can be just as significant.

The NTSB believes that California should apply its cell-phone ban for bus drivers and novice drivers to the general driver population. We also believe that California is the perfect state to lead the charge to develop technology that will help end this deadly problem.

As we learn more about the science of distraction and distracted driving, it becomes more and more obvious that, as distractions are eliminated, Californian lives will be saved.

Eliminate Distractions

By Vice Chairman Bruce Landsberg

The NTSB has investigated distraction-linked crashes in all modes of transportation. Our 2017 distracted driving roundtable, “Act to End Deadly Distraction,” made one thing very clear:

We don’t feel these losses in a statistical table. We feel them at the dinner table. We also don’t call them “accidents” because they are totally predictable.

More than 100 people die every day on our roads and highways, nine or ten of them per day in distraction-involved crashes alone. More than 1,000 people per day—391,000 in one year—are injured in distraction-involved crashes. And it’s certain that this number is greatly under-counted. Many of these injuries are life-altering, disfiguring and permanently crippling. My apologies for being graphic – but ask anyone who’s been involved whether the distraction that caused the crash was worth it.

Listen to stories told in our 2017 roundtable by survivor advocates. Or, simply ask around. It won’t take long to find someone with a story of a friend, business colleague or loved one lost to a distracted driver.

What too many of these crashes have in common is a portable electronic device – the universal cell phone. When the NTSB made its first recommendation about driver distraction by “wireless telephone” in 2003, cell phones were primarily just that: tools for making voice calls. Although some cell phones had keypads, the word “texting” does not appear in that early report.

In 2011, the NTSB recommended that the states ban non-emergency driver use of all portable electronic devices that did not support the driving task. To date, no state’s laws have gone that far. Why?

And since drivers look to the law for guidance, no state’s drivers have gone so far as to voluntarily stop driving while visually, manually, and/or cognitively distracted. Why?

Now, a second 2011 NTSB safety recommendation is becoming steadily more feasible: Safety Recommendation H-11-47. We recommended that CTIA—the wireless association, and the Consumer Electronics Association, encourage the development of technology that can disable portable electronic devices within reach of the driver when a vehicle is in motion (with the ability to permit emergency use of the device while the vehicle is in motion, and the capability of identifying occupant seating position so that passengers can use their devices).

Unfortunately, the recommendation has not been adopted, despite smartphones and apps that will allow the driver to opt out of calls and texts while driving. So, why hasn’t there been more action on this recommendation?

The best safety solution is always to design out the problem. Rather than just encourage people to do the right thing, don’t give them the opportunity to do the wrong thing… and possibly take a life or maim someone.

Don’t misunderstand, we endorse a solid tech solution, but such a solution won’t work in every situation. It must be a belt-and-suspenders effort, together with the familiar three-legged stool of highway safety (awareness, tough laws, and high-visibility enforcement).

This year many more loved ones will be lost to distraction, but surveys tell us that most people think distracted driving is a bad idea. Until, that is, we have to put our own phone down. Hypocritical? It couldn’t possibly happen to me – I’m too good a driver! The numbers prove otherwise.

Time, tide and tech wait for no man or woman, to coin a phrase. By the end of today a thousand more families will be dealing with tremendous loss and pain.

This month, the NTSB will host its third Roundtable on Distracted Driving: Perspectives from the Trucking Industry. During the roundtable, members of the trucking community, victim advocacy groups, the business community and legislators will come together to discuss the problem of distracted driving and potential countermeasures. We also hope to hear about new efforts to close Safety Recommendation H-11-47.

To kickoff Distracted Driving Awareness Month, on April 3, we will also host, with Impact Teen Drivers and the California Highway Patrol, the Western States Teen Safe Driving Roundtable to talk about the state of teen driving and the proven strategies for preventing teen-driving related crashes.  Now, what are you going to do about it?

When it Comes to Safety, Not All Flights are Created Equal

By Chairman Robert L. Sumwalt

Last week, we officially adopted our final report on the tragic May 15, 2017, crash of a Learjet 35A on a circling approach to Teterboro Airport in New Jersey. The crash took the lives of the two occupants—the aircraft’s pilots. The probable cause of the accident was the pilot‑in‑command’s (PIC’s) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude.

The accident airplane’s operator offered on-demand flights under Part 135 of the Federal Aviation Regulations. (The air carriers that most people are more familiar with, which fly regularly scheduled routes, are regulated under Part 121.) The accident flight was a positioning flight subject to Part 91 rules; however, the procedures that the operator used, the pilots’ training, and the Federal Aviation Administration’s (FAA’s) ongoing oversight duties all pertained to Part 135 aviation.

Imagine knowing that some of what was happening on this accident flight was going on in your regularly scheduled air carrier flight. First, the PIC was not flying the airplane until just before the accident, when the second-in-command (SIC) relinquished control, despite the fact that, by the company’s own standard operating procedures (SOPs), the SIC was not experienced enough to be flying. This was only one of many instances during the flight of an SOP violation or the failure to use required SOPs.

Additionally, during initial training, the PIC and the SIC both had difficulty flying circling approaches in a simulator. This Part 135 carrier, however, did not have a program in place to follow up with pilots who had exhibited issues during training. What’s more, despite both pilots’ training problems flying a circling approach, they were teamed together for this flight.

This accident flight was also an example of poor crew resource management (CRM). CRM done well results in SOP adherence and effective communication and workload management. However, during this flight, the captain had to extensively coach the SIC while also fulfilling his pilot monitoring responsibilities. He did neither well. Both pilots lacked situational awareness.

Contributing to the accident was the PIC’s decision to allow an unapproved SIC to act as pilot flying, and the PIC’s inadequate and incomplete preflight planning. Also contributing to the accident was the carrier’s lack of any safety programs that could identify and correct patterns of poor performance and procedural noncompliance, and the FAA’s ineffective safety assurance system procedures, which failed to identify the company’s oversight deficiencies.

In response to this accident, among other things, we recommended that the FAA require Part 135 operators to establish programs to address and correct performance deficiencies, as well as to publish clear guidance for Part 135 operators to create and implement effective CRM training.

This accident illustrates that Part 135 flight crew members don’t always follow the same procedures or exhibit the same discipline as professionals in Part 121 operations. Before the accident at Teterboro, we found that pilot performance either caused or was a major contributing factor in seven major aviation accidents involving Part 135 on‑demand operators between 2000 and 2015. A total of 53 people were killed and 4 were seriously injured in these accidents. This year, we added “Improve the Safety of Part 135 Aircraft Flight Operations” to our Most Wanted List of transportation safety improvements to help draw attention to this problem.

MWL06s_Part135

Many air carriers operating under Part 121 are required to continually seek and identify risks, and once the risk assessment is done, put measures in place to mitigate those risks through safety management systems (SMSs). Conversely, while some Part 135 operators have implemented SMS, most have not.  In response to the Teterboro accident, we reiterated a previous recommendation to the FAA to require that all Part 135 carriers in the United States have an SMS in place.  In Part 121 training, performance deficiencies are required to be followed up on; there’s no such requirement for Part 135 operators to monitor deficiencies in their pilots’ training.

Further, although Part 135 operators, like their Part 121 counterparts, are required to provide CRM training, they receive less thorough guidance on what constitutes effective CRM training. This shortcoming was evident in the Teterboro accident, where the crew did not display good CRM during the accident flight.

I’ve had two very interesting roles in life – being an airline pilot and serving as an NTSB Board Member. While serving as an airline pilot, I was also a member of a flight operational quality assurance (FOQA) team. In that role, I looked at minor procedural deviations in nonaccident flights with the purpose of learning where potential problems were. In this accident, we reiterated previous recommendations to the FAA to require flight data monitoring (FDM) programs to accomplish the same kind of oversight for Part 135 aviation, and that Part 135 operators install the necessary equipment to acquire FDM data.

In my role as an NTSB Board member, I have seen too many cases where accidents occur in part due to procedural noncompliance and lack of professionalism. A pilot might be born with certain aptitudes, but no one is a born professional; it takes work and constant discipline. Professionalism is a mindset that includes hallmarks such as precise checklist use, callouts, and compliance with SOPs and regulations. Those traits were conspicuously absent on this accident flight. And, now as my role as a frequent airline passenger, I’m glad that airlines are required to have SMS programs; I know they make my flights safer.

The NTSB believes that tools such as an effective SMS should be required and used in Part 135 aviation as well as by Part 121 carriers. We hope that including “Improve the Safety of Part 135 Aircraft Flight Operations” on our Most Wanted List for 2019–2020 will encourage action on this issue.